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A healthcare provider prescribes a higher-than-usual dose of medication. What is the nurse's first action?
- A. Administer the medication and monitor closely.
- B. Hold the medication and consult the pharmacist.
- C. Ask another nurse to verify the dose.
- D. Call the provider for clarification.
Correct Answer: D
Rationale: The correct answer is to call the provider for clarification. When faced with a higher-than-usual dose of medication, the nurse's first action should be to contact the prescribing healthcare provider to confirm the dosage. Administering the medication without clarifying the dose with the provider can pose serious risks to the patient's safety. Holding the medication and consulting the pharmacist may be appropriate after contacting the provider for clarification. Asking another nurse to verify the dose is not the most appropriate action when dealing with an unusual prescription; direct communication with the provider is essential in such situations.
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The nurse is assessing the patient for respiratory complications of immobility. What action should the nurse take?
- A. Auscultate the entire lung region to assess lung sounds.
- B. Assess the patient at least every 4 hours.
- C. Focus auscultation on the upper lung fields.
- D. Inspect chest wall movements primarily during the expiratory cycle.
Correct Answer: A
Rationale: Auscultating the entire lung region is the most appropriate action when assessing a patient for respiratory complications related to immobility. This approach helps the nurse identify any abnormalities in lung sounds, such as diminished breath sounds or the presence of secretions. Assessing the patient at regular intervals (choice B) is important but does not specifically address the respiratory assessment needed in this situation. Focusing auscultation on the upper lung fields (choice C) may miss potential issues in other areas. Inspecting chest wall movements primarily during the expiratory cycle (choice D) is not the most effective way to assess lung sounds and identify respiratory complications.
A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?
- A. Complete an incident report.
- B. Ask the colleague if they intend to report the error.
- C. Call the healthcare provider to notify them of the error.
- D. Notify the supervisor about the situation.
Correct Answer: B
Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.
A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter insertion site with alcohol.
- C. Insert the catheter as quickly as possible.
- D. Use a smaller catheter size to minimize trauma.
Correct Answer: A
Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.
A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?
- A. Encourage visitors during visiting hours.
- B. Keep the patient on fall precautions until discharge.
- C. Check on the patient every shift.
- D. Raise all four side rails.
Correct Answer: B
Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.
Which intervention is most effective for managing a patient with constipation?
- A. Increase the patient's fluid intake.
- B. Administer a stool softener as prescribed.
- C. Provide the patient with a high-fiber diet.
- D. Teach the patient to perform Valsalva maneuvers.
Correct Answer: B
Rationale: The most effective intervention for managing constipation in a patient is to administer a stool softener as prescribed. Stool softeners help relieve constipation by making the stool easier to pass, especially in postoperative patients. Increasing fluid intake can be beneficial but may not address the underlying cause of constipation. While a high-fiber diet is important for bowel health, it may not provide immediate relief for constipation. Teaching a patient to perform Valsalva maneuvers is not recommended for managing constipation as it can lead to adverse effects like increasing intra-abdominal pressure.